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Your Record of Hospital Insurance Benefits Used Under Medicare: Maria Hyun.

)
v DEPARTMENT OF 4
) HEALTH, EDUCATION, AND WL /ARE
Social Security Administration
YOUR RECORD OF HOSPITAL INSURANCE
BENEFITS USED UNDER MEDICARE
(THIS IS NOT A BILL)
[~ MARIA HYUN I
933 MALTMAN AV DATE: 7-09-68
LOS ANGELES CA 90026
YOUR CLAIM NUMBER: B
I I In any correspondence, please refer to this number.
Dear Beneficiary:
Recently, your Medicare Hospital Insurance helped pay for the services described below. We are pleased that
your social security program was able to assist you.
> 1. OUR RECORDS SHOW THAT YOU RECEIVED THESE SERVICES
SERVICES WERE PROVIDED BY TYPE OF SERVICES WHEN
For information about any services NOT COVERED by your Medicare Hospital Insurance, please see other side.
,. k HOSPITAL SERV Of SOUTHERN CALIFORNIA
If you have any questions about this ^ , .„-, cum cm- m %,r%
J , . . , . , ip 4777 SUNSET BLVD
record, please gee in touch with: W L0S ANGELES CALIFORNIA 90027
2. OUR RECORDS NOW SHOW THESE BENEFIT TOTALS
AVAILABLE TO USE FOR
THIS "SPELL OF ILLNESS"
USED THIS TIME TOTAL USED (See "D" on other side.)
INPATIENT HOSPITAL DAYS 3 3 87
EXTENDED CARE FACILITY DAYS HONE NGNE
HOME HEALTH VISITS NONE NONE
BEGINNING WITH JANUARY 1, 1968, YOU ALSO BECAME ENTITLED TO A LIFETIME
RESERVE OF 60 INPATIENT HOSPITAL DAYS*
► If you again use services which are covered by your Medicare Hospital Insurance, please show this Record
and your Health Insurance Card to the organization providing services.
SEE OTHER SIDE FOR ADDITIONAL INFORMATION.
sj bmcer
/uuy
Sincerely yours,
*f' Va/t>
Robert M. Ball
Commissioner of Social Security
FORM SSA-1533 (8-67)
TEMPLE HOSP INPATIENT 4-27-68 \
235 N HOOVER ST HOSPITAL T0 3
LOS ANGELES CALIFORNIA 900C4 4-30-68 \
0
Your Medicare Hospital Insurance has paid the cost of all COVERED SERVICES except: 1
$40*00 FOR THE $40 INPATIENT DEDUCTIBLE* \

)
v DEPARTMENT OF 4
) HEALTH, EDUCATION, AND WL /ARE
Social Security Administration
YOUR RECORD OF HOSPITAL INSURANCE
BENEFITS USED UNDER MEDICARE
(THIS IS NOT A BILL)
[~ MARIA HYUN I
933 MALTMAN AV DATE: 7-09-68
LOS ANGELES CA 90026
YOUR CLAIM NUMBER: B
I I In any correspondence, please refer to this number.
Dear Beneficiary:
Recently, your Medicare Hospital Insurance helped pay for the services described below. We are pleased that
your social security program was able to assist you.
> 1. OUR RECORDS SHOW THAT YOU RECEIVED THESE SERVICES
SERVICES WERE PROVIDED BY TYPE OF SERVICES WHEN
For information about any services NOT COVERED by your Medicare Hospital Insurance, please see other side.
,. k HOSPITAL SERV Of SOUTHERN CALIFORNIA
If you have any questions about this ^ , .„-, cum cm- m %,r%
J , . . , . , ip 4777 SUNSET BLVD
record, please gee in touch with: W L0S ANGELES CALIFORNIA 90027
2. OUR RECORDS NOW SHOW THESE BENEFIT TOTALS
AVAILABLE TO USE FOR
THIS "SPELL OF ILLNESS"
USED THIS TIME TOTAL USED (See "D" on other side.)
INPATIENT HOSPITAL DAYS 3 3 87
EXTENDED CARE FACILITY DAYS HONE NGNE
HOME HEALTH VISITS NONE NONE
BEGINNING WITH JANUARY 1, 1968, YOU ALSO BECAME ENTITLED TO A LIFETIME
RESERVE OF 60 INPATIENT HOSPITAL DAYS*
► If you again use services which are covered by your Medicare Hospital Insurance, please show this Record
and your Health Insurance Card to the organization providing services.
SEE OTHER SIDE FOR ADDITIONAL INFORMATION.
sj bmcer
/uuy
Sincerely yours,
*f' Va/t>
Robert M. Ball
Commissioner of Social Security
FORM SSA-1533 (8-67)
TEMPLE HOSP INPATIENT 4-27-68 \
235 N HOOVER ST HOSPITAL T0 3
LOS ANGELES CALIFORNIA 900C4 4-30-68 \
0
Your Medicare Hospital Insurance has paid the cost of all COVERED SERVICES except: 1
$40*00 FOR THE $40 INPATIENT DEDUCTIBLE* \